Connie Neal, MSW & Lisa Shannon, PhD, MSW NADCP Annual Meeting, July 2013

Transcription

1 Connie Neal, MSW & Lisa Shannon, PhD, MSW NADCP Annual Meeting, July

2 Explain the fundamentals of ACT as well as necessary modifications for implementing with an adult substance abusing population. Describe the key roles/responsibilities of the ACT and Drug Court team members. Examine evaluation data associated with the implementation of the ACT model in adult Drug Court sites. 2

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4 Kentucky is unique since it is predominantly a rural state. Differing trends rates of prescription opiate and benzodiazepine use higher than urban areas There is some evidence to suggest injection drug use rates are also higher in rural areas (Shannon et al., 2007; Shannon et al., 2010) Heroin use is also increasing; however this trend appears to be statewide. 4

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7 Assertive Community Treatment (ACT) is an evidenced-based practice designed to provide effective treatment and support services to the chronically mentally ill by extending services to those most difficult to serve. The Kentucky Administrative Office of the Courts has adapted the model to address the needs of an addicted population and implemented in eight drug court sites. 7

8 Integrates an existing evidence-based practice into drug court community-based programs targeting individuals with primarily substance abuse problems Perry and Floyd sites were funded in October, 2008 (projects ended ). Knox/Laurel and Hardin sites were funded in October, Daviess site funded in October, Knott/Magoffin sites funded in October, McCracken and Warren sites funded in October

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10 Unified Statewide Drug Court System Overseen by the Kentucky Administrative Office of the Courts, Statewide Services Department, Division of Drug Courts Executive Officer and Manager Programs are either single or multi-county jurisdictions, mainly rural, and are operated locally by Drug Court Staff 10

11 Program Supervisor: Responsible for administration of the program and supervision of drug court case specialists. Case Specialists: Responsible for all supervision, monitoring and case management of drug court participants. (cases are transferred from the Department of Probation and Parole to the drug court via court order) Assistance with curfew checks and home visits provided by local law enforcement agencies via either Memorandums of Understanding or verbal agreements 11

12 Treatment services are provided by the local Community Mental Health Centers via Memorandum of Agreements with the AOC Ancillary services are provided by local community service agencies 12

13 Along with the traditional drug court approach to supervision and case management, participants in grant-funded services receive intensive support and assertive outreach in their own living and working environments via ACT. ACT has an anticipatory approach and provides for intensive, ongoing assessment of immediate and long term recovery related needs. Ideally, the implementation of ACT in drug court settings will increase access to needed services and decrease the likelihood of relapse and related criminal activity. 13

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15 Maintaining a substance-free lifestyle Lessening symptoms of co-occurring disorders Maintaining decent and affordable housing Minimizing involvement with law enforcement and criminal justice Acquiring and keeping a job Maintaining a good general health status Helping the individual meet other goals 15

16 Services are provided in the clients home as much as possible Team members practice assertive outreach to clients Highest possible intensity of services Caseloads are small Team members available 24/7 16

17 Relationship with team, not individual Team works with community to provide supportive relationships Team provides continuity of staffing 17

18 A review of the extant research suggests strong support for the ACT approach. Specifically, ACT is associated with: 1) reduced symptom severity; 2) enhanced residential stability; 3) enhanced role functioning, including employment status; and 4) improved quality of life (Stein & Santos, 1998). Developed and tested for persons with severe mental illness, however the outcomes associated with ACT directly overlap with goals of the Drug Court program. 18

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20 ACT uses a trans-disciplinary approach Team members conduct comprehensive assessments and intense ongoing evaluations The entire team is jointly responsible for implementing and monitoring the plan Weekly (minimum) team meetings with ongoing transfer of information, knowledge, and skills shared among team members (cross-training) Participant has an active voice in plan development and method of implementation 20

21 Provides intensive and ongoing assistance with: Activities of daily living Housing Family life/social relationships Employment/education Managing finances Health care/medications Counseling/co-occurring disorders/higher levels of care 21

22 Rather than referring participants to multiple service agencies, the ACT team provides direct services as much as possible Rather than working with participants solely in the office environment, ACT team members work with participants in the environments where problems and stresses arise where they need support and skills (i.e., home, work, neighborhood) 22

23 No limit on length of services, may have decreased contact with participants over time, but remain available if/when needed Actively solicits input to clearly identify barriers to recovery and input on goals and methods to remove barriers Participants who are seen as noncompliant are given more intensive services rather than terminated 23

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25 While ACT was primarily developed for persons with severe mental illness, these projects utilize ACT for those with dual diagnoses as well as those with only substance use disorders. Thus, at times, these projects modify ACT by substituting substance use for mental health. This modification is minor and has been considered valid (Stein & Santos, 1998). Being free of substance use has always been a goal of ACT, but not the principle focus as it is in these projects. 25

26 While the traditional model involves a medically-oriented team, this ACT team is comprised of the counselor, case manager, peer recovery specialist, the ACT Clinical Supervisor and the Drug Court Program Supervisor/Case Specialist. 26

27 In order to address gender issues, if possible two peer recovery specialists are hired, a male and a female. The use of home visitation and assertive outreach to clients has been modified for cultural issues related to fear and suspicion about governmental services. 27

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29 In addition to the drug court team in this adapted model integral ACT team members are: counselor, case manager, and peer recovery specialists. This model adds an additional counselor and case manager to enhance and target services to individuals with the most significant needs. 29

30 Liaison with ACT team and traditional drug court team Community Supervision Assist participant with identifying barriers to recovery and plans to remove them Overall support 30

31 Individual/group/family counseling Addresses mental health/co-occurring disorders Assist with medication needs and monitoring compliance Evaluate for higher levels of care Assist participant with identifying barriers to recovery and plans to remove them Overall support 31

32 Conduct initial and ongoing needs assessments Assist participant in identifying barriers to recovery and plans to remove them If team cannot provide services, refers to appropriate service agency and follows up to ensure service is received Services are located/developed to fit participants stated goals/needs Visits to home and place of employment Assist with most basic recovery needs (i.e., transportation, food, shelter) Overall support 32

33 Assist participants with identifying barriers to recovery and plans to remove them Assist participants with identifying stresses and plans to deal with them Visits to home and place of employment Assist with most basic recovery needs (i.e., transportation, food, shelter) Relapse identification and prevention Overall support 33

34 Judge Judge Kimberly Childers Drug court program supervisor Glenda Shrum Counselor Adam Rice Case Manager Trevor Jacobs Peer Recovery Specialist Summer Little 34

35 Major changes in programming since the grant was implemented? Additional services provided by your agency supported by the grant? How have the services provided by this grant influenced or complimented the current system of care? How do the grant-funded services help clients in maintaining recovery in substance abuse? How do the grant-funded services help clients to set goals for their future? 35

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37 Data help monitor the implementation from provider perspectives. Provides descriptive information about program services, program changes following implementation, perspectives on program successes, and proposed program recommendations. 37

38 Face to face interviews were conducted with administrators and staff directly involved in the project implementation/services from the grant sites. Interviews were scheduled at the convenience of the participants and lasted approximately fifteen minutes. 38

39 Improvements to participants quality of life (i.e., education, financial assistance, transportation, wraparound services) Reduced substance use Reduced barriers (i.e., new teeth/dentures, identification) Ability to serve more participants Peer support services allows for relationships to be built with community agencies. 39

40 Communication/collaboration at start-up Referral process to the ACT team Availability/amount of wraparound funds Getting individuals into treatment/ services more quickly 40

41 Accomplishment of goals Elimination/reduction of barriers Improved quality of life Sobriety Employment Program compliance (i.e., phasing up, continued service utilization) 41

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43 The outcome evaluation assesses the effects of the grant-funded program on participants receiving enhanced services at six-months and discharge. This component of the evaluation examines baseline characteristics of clients entering the program and changes in outcomes. 43

44 Participants were 377 individuals who completed a baseline and follow-up interview as part of an outcome evaluation project. Further, all individuals included in this analysis had been discharged from drug court. The outcome evaluation project focused on Kentucky Drug Court sites in: Daviess, Floyd, Hardin, Knott/Magoffin, Knox/Laurel, and Perry counties. These sites were included because all had received grant funding from the Department for Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) to enhance existing services. 44

45 Government Performance and Results Act (GPRA) - derived from the ASI, the GPRA items provide useful measures of current substance use and related behaviors. In addition to GPRA: Addiction Severity Index-5 th Edition: The ASI is used to measure life problem areas including psychological/mental health status, physical health status, housing, employment, drug and alcohol use, legal, and family-social functioning (McLellan et al, 1985; McLellan et al., 1992). 45

46 Outcome evaluation data are collected at: 1) baseline, 2) 6 months post-baseline, and 3) discharge. Baseline and follow-up data were collected by a Research Assistant (RA) who interviewed program participants for the CSAT evaluation. Once the program coordinator identified a potential participant, the RA met with the participant, provided information about the evaluation, discussed components of informed consent, and if the participant agreed, administered the evaluation interview through a face-toface interview. Evaluation data were collected via a laptop computer with the CSAT Evaluation Data Entry System (CEDES) system. 46

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48 (N = 377) AGE (range 18-57) GENDER RACE Male 54.1% Female 45.9% White 91.5% Black 8.5% EMPLOYMENT % Employed, full-time 26.3% % Unemployed, looking for work 41.1% 48

49 (N = 377) MARITAL STATUS Never married 49.9% Married 16.4% Divorced 20.2% EDUCATION Less than high school diploma 39.0% High school diploma/ged 36.3% Some college or more 22.9% 49

50 Marijuana Alcohol 98.7% 97.1% Opiates Benzodiazepines Cocaine 84.6% 82.2% 80.4% Crack Cocaine Methamphetamine 49.6% 56.2% 50

51 Anxiety 59.2% Depression 50.7% Understanding 44.3% Prescribed Mediciation 17.5% Violent Behavior 15.4% 51

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53 Excellent follow-up rates! The overall follow-up rate for the period of data collection (01/16/ /01/2012) was 96.3%. Individual sites ranged from a high of 100% follow-up rate to a low of 88.6%. 53

54 Baseline Follow-up 58.3% 44.5% 26.3% 32.9% 13.0% 14.9% Full-time* Part-time Unemployed*** * p<.05, **p<.01, *** p<

55 Baseline Follow-up 86.5% 63.1% 70.6% 36.9% Alcohol*** Illicit/Illegal Drugs*** *** p<

56 Baseline Follow-up 50.7% 36.9% 59.2% 48.0% 44.3% 32.1% 15.4% 8.5% Depression*** Anxiety** Understanding** Violent Behavior** **p<.01, **p<.01 56

57 Baseline Follow-up 39.0% 8.5% *** p<.001 Arrests Past 30 Days*** 57

58 Average length of time in Drug Court was days (SD = ). 58

59 No comparison group can not definitely determine the cause of the change, the service enhancement or drug court services, in general. 59

60 Chief Justice Minton, Laurie Dudgeon, Connie Payne Daviess, Floyd, Hardin, Knox, Laurel, Knott, Magoffin, McCracken, Perry and Warren: Judges Drug court teams Community Mental Health Centers Other community partners - treatment providers, doctors, other service providers Evaluation team members 60

61 Burns, B. & Santos, A. (1995). Assertive community treatment: An update of randomized trials. Psychiatric Services, 46, Joe, G., Broome, K., Rowan-Szal, G., & Simpson, D. (2002). Measuring patient attributes and engagement in treatment. Journal of Substance Abuse Treatment, 22, McLellan, A., Kushner, H., Metzger, D., & et al. (1992). The fifth edition of the addiction severity index. Journal of Substance Abuse Treatment, 9, McLellan, A., Luborsky, L., Cacciola, J., & Griffith, J. (1985). New data from the Addiction Severity Index: Reliability and validity in three centers. Journal of Nervous and Menta Disease, 173, 423. Shannon, L., Havens, J.R., & Hays, L. (2010). Examining differences in substance use among rural and urban pregnant women. The American Journal on Addictions. Shannon, L.M., Havens, J.R., Mateyoke-Scrivner, A., & Walker, R. (2009). Contextual differences in substance use for rural Appalachian treatment-seeking women. The American Journal of Drug and Alcohol Abuse, 35(2), Stein, L. & Santos, A. (1998). Assertive Community Treatment of Persons with Severe Mental Illness. New York: Norton Books. Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2006). Results from the 2005 national survey on drug use and health. Rockville, MD: Office of Applied Studies. 61